20 September 2011

I am always amazed at the viciousness that pops up in the comments when I post about the uninsured, and the human consequences of being uninsured. I've been running this blog for six years now, and it's been a reliable and persistent phenomenon. In my most recent post, about the guy who died of a dental infection, an anonymous commenter, no doubt a good christian, left this gem:

So I'm supposed to feel bad for this guy, pay more taxes to help fund a government program that will "help" this lazy person, all the while I have to provide free care to him in the ED, take money away from me that I earned through hard work, [...] What happened to this man is terrible, but I have no sympathy for him or his family. He refused to seek out ways to help himself. This is in no way my, or your responsibility.

To paraphrase, "Fuck him, the lazy mooching bastard got what he deserved. I got mine." I mean, wow. To describe this as callous indifference doesn't do it justice. Curiously, this sentiment is common and almost exclusively voiced from the political right. Christ talked quite a lot about universal charity and caring for one's fellow man, but for a non-trivial subset of conservatives, the gospel of "personal responsibility" trumps those other gospels, I guess.

Based on the commentariat here, I don't think that's an aberrant example of the ethos of the libertarian right. I do not think that's representative of all conservatives -- at least I fervently hope not -- but it is representative of some of the most active and vocal republicans, and particularly those who are driving the policy bus these days. Aaron Carroll at TIE thinks it's a product of hyperpartisanship: "Many people wanted their side to “win” so badly that they began to delight in victory and the political game to a point they forgot that we were discussing very important issues with a human cost." Maybe he is right, but the consequence of championing this sort of policy is the mental gymnastics people need to go through to convince themselves that their favored policy would not result in people dying or suffering unnecessarily.

The same commenter above added:

Hypothetically, shadowfax, if you had no insurance and your wife was diagnosed with her breast cancer, would you just buy the vicodin and say, "nice knowing you honey?" I'm sure you would seek ways to help get her the treatment she needed.

Sure, I would seek help. But like too many others, I'm reasonably certain that either I would not find it, or even if we did, major compromises would have to be made in the quality of her care. That's a hard and fast rule of being indigent and sick. Things get delayed and some things you just don't get. As an additional bonus, even if we did get some limited charity care, our family would suffer financial ruin as a result. The cost of chemo alone is well over $100,000, not to mention surgeries, radiation, hospitalizations, imaging and many ancillary tests. It's pure fantasy to think that someone would give us that for free. Conservatives talk about communities banding together to help a member in need -- church bake sales and the like. But the ability of individual voluntary donations to raise the amount of funds needed to care for a serious illness is equally fantasy.

A case in point -- a sad and highly ironic one -- was that Dr Ron Paul's former campaign manager, a man who managed to raise $19 million in political donations -- became ill and died of pneumonia in 2008 at the very young age of 49. He was uninsured -- he wanted to purchase insurance but was denied due to a pre-existing condition -- and the medical bills totalled $400,000. His friends started a financial fund to offset the costs. It raised $35,000. This was a well-connected person whose whole life revolved around raising money, and private charity failed to cover his medical bills by an order of magnitude. Why would anybody think that this is a reasonable and sustainable strategy for others, especially those who are in lower-income communities? What about those who are socially isolated and don't have a church or a large group of friends?

Steve worked 14 hours a day building beautiful guitars ... he barely eked out an existence with financial help from my husband and me. Money for health insurance? Don’t be ridiculous.

He was 63. He had to start Social Security early so he could afford to eat. He was too young for Medicare and too male for Medicaid. This nation does not recognize the years he spent working for others and making this economy grow, it only focused on the years he worked for himself, creating instruments of rare beauty.

When he had a pain in the butt, he had to wait until early in the morning of December 3rd to present himself at the ER of Highland Hospital, the Alameda County medical facility. There are guards at Highland, and a football field full of plastic chairs for the indigent to use while they wait treatment. He was sent home with a handful of Vicodin and a suggestion to follow up with a pulmonologist for the 3 cm spot the Xray showed on his lung. The soonest appointment was Feb 25.

He was in so much pain that he could not stand up for more than a few seconds at a time. He got Vicodin. And steroid suppositories. His buddies came up with the $2000 a proctologist wanted to do an outpatient surgery. But the hospital wanted $20,000 for use of the room for the brief procedure because he was uninsured.

Three months to see the specialist. When my wife was diagnosed, we got next-day appointments. I'm not asserting that her brother would have lived with better access to care -- sounds like he was palliative from the get-go -- but he probably would have suffered less, and statistically, some of the 50 million uninsured out there will die because of their limited access to care. And those who are lucky enough to get delayed, poor-quality charity care get it subsidized by the rest of us, as it is.

But the attempt to remedy the problem, initially proposed and embraced by conservatives, has disingenuously morphed into an un-American assault on liberty. The irony is pointed out by Danny Westneat of the Seattle Times:

So who should pay? Right now, we all do.

What was so provocative about the question is that the health-reform plan routinely denounced as socialist — so-called Obamacare — seeks to get the freeloading guy to pay his own way. He'd have to get insurance or be fined. He'd pay for it himself, unless he were very poor. The idea is then there'd be no need for the rest of us to pick up his huge charity-care bills.

It's true that coercing people to buy insurance is not "freedom." But what's so aggravating about the health-care debate is that neither is what we have today. It sure seems socialistic that all of us have to cover the uninsured guy's bills, as we do today. Yet an effort to stop doing that — to try to get him to pay for himself — is what gets derided as un-American.

But, fuck them, because I've got mine. Am I right? They're lazy, irresponsible, poor, probably black, certainly unwashed and they have nice cell phones, so they are subhuman pieces of shit who deserve what's coming to them. And an individual mandate is an unconscionable impingement on my personal liberty.

This is, as best I can tell, the libertarian take on the ongoing crisis of the uninsured. We are all free, and some lucky duckies are free to die.

I apologize in advance to those conservatives and libertarians who are offended. I'm angry and I am ranting. I know you are not like those bad libertarians. Please go ahead and explain in the comments how the free market and the personal responsibility fairy will fix the system, or just point to the Republican health care proposal which will replace Obamacare when it is repealed. I've been waiting for quite a while to see that one, but they seem stuck on "repeal" with no clear plan to "replace."

65 comments:

Hi, I have never read your blog before but this post was sent to me because I am a huge advocate for health care for all. I want to add even more to your rant, because I agree with you. First off, I am so dismayed by the lack of compassion for the sick by so many people... it bothers me. When we refuse to look at the humanity of a situation and would honestly say... let them die instead of me having to spend an extra dollar a week or so in taxes, that scares me because you never know when something may happen and you may be one of the millions who are uninsured in America. I have family and friends currently who have no coverage...some are students, some are adults whose jobs do not offer insurance and they could not afford the staggering costs of personal insurance on their own, so if something were to happen to them tomorrow... I am sure the vocal and scary people represented on your blog would say... screw them... wow...just wow. I wanted to add another issue to your rant, one that is also going on. I am one of the lucky ones with health insurance, but I have a disease. Each time I get a new medication from my doctor... I have to argue with my insurance company over the necessity of it (because my medications are expensive). I have to haggle over my own care that I pay for through insurance. It is hard for me to work, I have rheumatoid arthritis and I work in a physically active job, but I keep my job to maintain my insurance. So I work in pain and I don't take my medication on days I work to ensure I won't get sick and then I go to the doctor and still have to worry about paying an extremely high co-pay and worrying if I can even get my medication (it has been denied multiple times and then my medication copay was tripled for one of my medications making it almost unaffordable). This is the reality of health care right now. Those who have no insurance die because they cannot seek care and those who even are lucky enough to have insurance sometimes have to decide whether to pay a bill or get medication. It should not be that way.

"This is, as best I can tell, the libertarian take on the ongoing crisis of the uninsured. We are all free, and some lucky duckies are free to die."

Actually, all of us are free to die because all of us ARE going to die. Maybe today, or tomorrow, or 50 years from now, but every one of us will face death. And thanks to advances in emergency medicine most of us will face a slow decline in health and then death with tremendous medical costs (including drugs).

I am horrified at stories like the man dying from an infected tooth. I want every human to have access to decent medical care, BUT is that even possible? Will there ever be enough money to provide good, timely medical care to every living soul in our country?

First, the guy who died from a tooth infection. Universal care supporters love this example because it shows a man that would have lived with proper care. But would he have gotten proper care if it were free? Four dollars isn't much of a barrier. The fact is people make bad choices and they don't all come down to money. Even his aunt said "He should have gone to the dentist to take care of the toothache."

Second, the guy who died from pneumonia and piled up $400K in bills. First of all, he didn't die because of lack of insurance. He got proper care (arguable since he died) but if left his family with $400K in debt. So, universal care wouldn't have saved his life, only his money. The first "wow" for me here is that doctors and hospitals can charge $400K to treat pneumonia and still let him die. Maybe, health reform needs to look there. Let's only pay doctors that actually fix their patients. Of course, this isn't practical but neither is simply having the government pay all bills because it won't help stem the unsustainable rise in healthcare costs.

The last case is harder to analyze because the only information comes from an emotional relative. It sounds like his care should have and could have been better but it is hard to say. Perhaps, a universal care system would have denied him care because he was palliative, as you say. Perhaps, it would have squeezed him in sooner at the expense of some other guy who had a chance of recovering if seen quickly. The one thing I am certain of is that we can always cherry pick cases that fit our views. With this one, you've done a decent job. The other two are kind of weak.

Finally, before you accuse me of being heartless, I believe society should provide care for those that truly need it and can't afford it but there has to be some type of personal accountability and there has to be some way of controlling costs.

I'm a big fan; I've read your blog for a long time. Thank you for writing this. The disconnect between reality and many of our fellow citizens is mind-boggling. You write about it very well. Thank you for this.

Apparently, he believes that everything is a zero-sum game. If someone somewhere gets medical care, there's less for him.I am so old I remember when the "American way" was to look after the poor and sick. We didn't always do such a great job of it but the "I've got mine, Jack and fuck the rest of you" attitude was not respectable. Now it's mainstream.

One of the many reasons I emigrated to Canada seven years ago was that I didn't want to face old age without reliable medical care. Here in BC, they're always scrambling for more money but the care I've received has been excellent. There was much resistance (from doctors, mainly) when the Canadian system came into being. Now, not even the Conservatives dare to touch it and Tommy Douglas (the politician who began it) is universally revered.

The people I know here are horrified at the situation in the US and can't believe the things that were said at the Rep debates. (No capital punishment here either.) Canada is far far far from perfect but I'm inclined to agree with them.

I know I took the (relatively) easy way out but I'm 70 years old now and you folks will just have to take up the struggle without my small contribution. Good luck.

There is no justice in our current system. The law obligates physicians to do everything they can to save the life of a drunk driver involved in an accident, but not a child with leukemia. This is a society where we pay physicians who treat the elderly more than those that treat children. This is a society where the janitor who works for the school district or Boeing never worries about paying a medical bill, while the self-employed janitor doesn't have health insurance at all.

No one should be forced or coerced into being charitable. Obamacare is mandated charity, which is completely ridiculous.

Free markets, while admittedly imperfect, are a better alternative. Cost/quality is maximized when left to the natural forces of open competition. Just look at the entire tech industry - cost goes down and quality goes up, there are no mandates and the market has free entry (mostly). It is in the producer's best interest to make tech affordable to the consumer so that they can beat their competitors. This cannot be said of healthcare, as the producer's best interests are not defined by the consumer but by the law. Their competitors are not other healthcare providers. They don't have any real competitors, thus prices will go up and quality will remain poor. This is a situation where the consumers will lose every time.

I'm sorry Jack, but you are talking pure nonsense .. the cost/quality equation for US healthcare is the worst in the world by far, and is markedly better in countries with systems as varied as Canada, Cuba, the UK, Singapore and Norway. The US spends far more on healthcare because of out of control market forces than any other country in the world and gets far far less actual health in its people in return. There is no point trying to impose another country's system on the US, they developed organically from the existing healthcare infrastructure and culture in each area, but not one of them operates the kind of market forces you so admire. If the US is to have a healthcare system worthy of its people, it will have to change.

Just because some people take a callous approach to other peoples lives does not mean that their ideas are ridiculous. No one is obligated to pay for other peoples troubles. Its a noble act to give to others. Just like you cannot regulate morality you cannot regulate and force people to pay charity. Universal Health Care is a Government regulated Charity and will fail to provide for all. End of story!

Agree with above that a lot of this comes from fear (it is THEM, not ME). The truth is, I just did business w/ someone who lost everything over medical bankruptcy. They had insurance but it wouldn't cover necessary surgeries for their child, so that, along with economic downturn, lost them everything. MOST people are truly an illness away from losing everything. When you are sick is the worst time to be fighting over benefits. We need universal healthcare with private options, if desired. It is the logical thing to do, both financially and compassionately.

I would like to point out that 100 years ago, the medical community decried the health care crisis, and demanded Government intervention. The Problem? Medical care was too inexpensive. The Solution? limit the number of hospitals, create highly restrictive cartels that all doctors must join, and restrict the founding of new medical schools. Their solution worked, now instead of being able to buy a full year's worth of medical care for only one day's wages, as was the case previously one must cough up several day's wages each month to buy the ever more costly Pre-paid medical care plans that the government insists we all must buy. The problem that we have with medical care in this country is excessive government interference in the field. The solution is the separation of doctor and state, not even more state interference.

Now, will this mean that some people will die untimely deaths because the free-market is not providing for them? Unfortunately it does. But how is that any different than the system that we currently have in place? In every field where a free-market has ever existed it delivers higher-quality goods and services for ever decreasing quantities of money that enables greater percentages of the population to pay their own way. I don't want to see people die untimely deaths, but the fact of the matter is that the government's involvement in medical care is more deadly than the free-market alternative.

Forced charity is already upon you, you just don't notice it. When an uninsured comes to the ER, they MUST be treated, this is the law (EMTALA 1986) Signed by Reagan.

According to the Centers for Medicare & Medicaid Services, 55% of U.S. emergency care now goes uncompensated. Lets be realistic, these costs don't just disappear, and the doctors don't just say "Well, pay me 55% less then". These prices get pushed on insurance companies which push them onto the people WITH health insurance.

What amazes me is that people born into this world automatically assume that they are entitled to things just for being alive. As if some higher power comes down from the heavens and magiacally provides these things. Healthcare costs money. You can't have laws like EMTALA without mandated coverage. If you want to mandate care, you have to mandate coverage. Otherwise don't do either. Mandating coverage takes away a person's right to choice.

Forget medicare reform. Fix the income inequality gap in this country and you won't even feel the need to mandate these things on people since they will be able to afford them without government assistance.

While Nathan was drinking the free market Kool-Aid, I was earning a degree in economics.

First of all, the "free market" is nothing more than an ideological construct. All markets are affected by public policy to some degree.

Secondly, less regulation does not always lead to a more ideal allocation of resources. There are well researched causes of market failure and the health care market suffers from many of them. Just to name a few: information asymmetry (between patients, providers, and insurers), externalities (infectious disease), and market power (insurers and providers).

You write, "an anonymous commenter, no doubt a good christian, left this gem." First, the person is not a good Christian. Being a good Christian is not based on what you believe but what you do. At least, that is what Jesus is reported to have said over and over again. Second, and related, you can take heart in Matthew 25, which says that people who do not help the sick and the poor will go to hell. And people who do help the sick in the poor will enter the Kingdom of God. Whatever going to hell and entering the Kingdom of God mean, according to Matthew 25, a devout atheist like yourself is in, and a selfish bastard like the anonymous commenter is out. As Bill Murray says, so, you got that going for ya, whichisnice.

Medical care in the US is bad because of government regulations. For example, why federal government limits number of doctors in the US? As of the last year 20600 doctors were allowed for residency and more than 45000 graduates applied for these positions. That's one of the reasons medical care is so ridiculously expensive.

"Medical care in the US is bad because of government regulations. For example, why federal government limits number of doctors in the US? As of the last year 20600 doctors were allowed for residency and more than 45000 graduates applied for these positions. That's one of the reasons medical care is so ridiculously expensive."

There is an important distinction you are missing. The federal government will only pay for so many residency positions, it does not say that a residency position cannot be created with private money. You think you are complaining about "government regulation", but in reality you are saying that the government should be subsidizing medical education to an even greater extent than it already is.

As an outsider looking in from north of the border, it's the single worst characteristic of being "American" - granted, an over simplification.

Your healthcare debate has always stunned me : the pure selfishness and lack of compassion for one's countrymen not as privileged, is a world in which I could not live.

I thank my lucky stars every day that I am able to practise medicine in a gentler society, and I lose no sleep over my higher taxation rates guaranteeing that my fellow countryman will not bankrupt himself due to medical misfortune.

I know for a fact that Standard Oil did exist, it did have the largest market share in its industry and that it was already waning in the market before the government stepped in and broke it up. If you are concerned about monopolies you should take a look at all of the monopolies that have been created by the ideological construct called the state. An institution that grants to itself the monopoly privilege of violence is inherently immoral and needs to be abolished. All coercive force(initial violence) is immoral, based on the Non-Aggression Principle, mandating how anyone spends their money through government action is violent.

Also, we must remember that the founder of the Mayo Clinic, William Mayo, was one of the most respected physicians in the country, despite that fact that he never obtained a medical license. The free market has worked in the Medical industry in the past, ask an economic historian like Michel Accad, and it can work again.

Annon: "You think you are complaining about "government regulation", but in reality you are saying that the government should be subsidizing medical education to an even greater extent than it already is."

Actually, this is one of the problems with this type of government influence. The government subsidized residence are "free" therefore a privately funded resident cannot compete. That person would need higher pay to pay back that private funding. If the government did not subsidize any residencies, then the market would compensate by finding a private mechanism and all residents would be on the same footing.

Arbitrary government regulations like this (AMT is another example) have issues because they are set at a fixed value until the problem gets so bad that someone proposes a solution and the cycle repeats. One significant benefit of a free market is that it reacts quickly to market forces. The government does not. We need more doctors yet the government has changed the number of residencies available in 14 years.

Why is profit bad for corporations and their shareholders but not for you? Forgive me if I make assumptions, but I suspect your hourly salary provides you a significant profit when compared to your investment in your education. Canadian doctors are paid on par with US doctors but if you don't think healthcare should provide a profit, shouldn't you work for much less?

"Actually, this is one of the problems with this type of government influence. The government subsidized residence are "free" therefore a privately funded resident cannot compete. That person would need higher pay to pay back that private funding. If the government did not subsidize any residencies, then the market would compensate by finding a private mechanism and all residents would be on the same footing."

Your rant makes no sense from an economic perspective. Price (where the supply and demand curve meet) is set on the margin. It is indifferent to the rest of the supply and demand curve.

If the market was efficient, residency slots would be created until the marginal cost of the residency equaled the marginal benefit. The fact that the first 20,000 or so residency slots had a marginal cost of zero would make no difference.

Essentially you have two options for conclusion... The market for residency slots is not efficient, or the marginal cost of a residency exceeds the marginal benefit. In laymans terms, either the market is inefficient, or there is an oversupply of doctors leading to too low a price for their services.

Your conclusion of an efficient market, too few doctors, and too high a price for medical services is logically incoherent.

Are you honestly arguing that Standard Oil achieved its profits and market dominance through being the most efficient producer and distributor of refined oil products?

Yes, that is exactly what I am arguing.

The mechanism of predatory exploitation of consumers requires substantial monopoly power that is used to increase prices, thereby reducing the outputs sold. But Standard Oil had no initial market power, with only about 4 percent of the market in 1870. Its output and market share grew as its superior efficiency dramatically lowered its refining costs (by 1897, they were less than one-tenth of their level in 1869), and it passed on the efficiency savings in sharply reduced prices for refined oil (which fell from over 30 cents per gallon in 1869, to 10 cents in 1874, to 8 cents in 1885, and to 5.9 cents in 1897). It never achieved a monopoly (in 1911, the year of the Supreme Court decision, Standard Oil had roughly 150 competitors, including Texaco and Gulf) that would enable it to monopolistically boost consumer prices. So it can hardly be argued seriously that Rockefeller pursued a predatory strategy involving massive losses for decades without achieving the alleged monopoly payoff, which was the source of supposed consumer harm. --Gary Galles

"Standard Oil did not use predatory price cutting to acquire or keep monopoly power." --John McGee (Journal of Law and Economics)

[T]here has never been a single clear-cut example of a monopoly created by so-called predatory pricing… claims of predatory pricing are typically made by competitors who are either unwilling or unable to cut their own prices. Thus, legal restrictions on price cutting, in the name of combating "predation," are inevitably protectionist and anti-consumer…" -- Thomas DiLorenzo

Historians that actually study the market shares and prices of the companies involved with a willingness to cut through the propaganda of a full century of belittlement have concluded that it was in fact efficiencies in Standard Oil's business model that enabled it to increase it's market share. However, it became inefficient as it grew, started losing market share, and then got broken up. The free market was providing higher quality goods at lower prices, with new competitors entering the market to try and meet the demands of the consumer.

The AMA is a cartel that limits entry into the medical field, despite the fact that some of history's greatest doctors were unlicensed. Medical schools get to veto plans to open new competitors in their area, again limiting the availability of new doctors. The market is not free; the government expressly calls for cartelization of the field through licensing boards and barriers to entry policed by those already in the fold.

Standard Oil accumulated market power through controlling the transportation of oil from the oil field to market, not through predatory pricing. Regardless of the nuance, they accumulated market power through restraint of trade and not by offering consumers the lowest prices.

I feel it is sad that the person died. However your comments on Christ and Charity are wrong. Charity is the willing giving of money to those you chose. This doesn't mean it can't be anonymous. When it is anonymous and out of my goodwill one would feel good about themselves.

Taxes on the other hand are not charity. It is taking of my hard work and giving it to someone we won't know or ever hope to know. We can't feel good. We just feel robbed and wonder what shmock is using our money for some "good weed."

We also don't like how our money at this point in time will likely go to paying the Chinese. People we didn't want to owe money but were forced to by a reckless government.

We dislike obamacare because it goes to those we didn't choose or "deem worth it." I honestly wonder how many people will over dose on some painkiller.

We also don't like this program because it forces us to buy a product just by simply living. Not the "free America" stuffed down the throats of Kindergartners.

Finally if we don't have but can afford it we are penalized large sums of money.

I am not trying to be mean. I am simply saying that this system is so flawed and unfair it should be obvious.

"The Republican health care plan: don't get sick. The Republicans have a back up plan in case you do get sick ... This is what the Republicans want you to do. If you get sick America, the Republican health care plan is this: Die quickly!"

I don't understand what you're saying Shadowfax. Penicillin is cheaper than a pack of cigarettes, a 12-pack of Pepsi (unless you got a rockin' coupon) or a #3 at McDonald's. Are you implying that this person had NO CHOICE but to not fill his prescription due to lack of insurance? The $4 PCN is the same cost whether you have insurance or not. Most prescription co-pays are $15 or $25 for the well-insured or less if the total cost of the medication is less.

You do have freedom to choose McDonald's over PCN or narcotics over PCN. There is a human brain controlling the decision-making capacity here. The human brain sometimes does dumb crap that gets you killed. Maybe he was an addict like so many people who deliberately let their teeth rot to get a steady supply of narcotics and it backfired. We don't know.

If you think the uninsured lack the ability to make informed decisions, you should lobby the state to have all treatments forced upon them like psychotic patients. I don't think that would go over well.

I pointed out in your previous post that dental isn't covered in Western socialist-medicine plans anyway. Again, don't understand what you're asking for. You want the government to force care on the insured, putting them in the same category as the intoxicated, mentally ill, or mentally retarded?

Anon: "Your rant makes no sense from an economic perspective...Your conclusion of an efficient market, too few doctors, and too high a price for medical services is logically incoherent."

First of all, you and I have different definitions of "rant." I try to avoid emotionally charged words in an attempt to maintain rational conversation. I realize this is a pointless goal with many people, but I try.

Second, I never claimed we have an efficient market. I believe I was implying the opposite: that government intervention prevents an efficient market. Not only does the marginal cost jump after you get past a certain number of residents but it is known in the market that the marginal cost will return to zero at the beginning of the next cycle. Therefore, the supply is held roughly constant artificially while demand increases which, of course, leads to a rise in price.

You are absolutely right about the problem, it must be addressed, and it will cost money, though perhaps we would disagree on the solution. However, the guy with the dental problem did not die because of problems in the health care system. He had the ability to get the meds he needed, and he had access to dental care. Certainly that access was inconvenient. It would have involves waiting around at a clinic all day, but as I pointed out in that thread, where he lives there are a lot of options for free dental care, readily available if inconvenient. They have much better resources than we do in this area. This guy died of poor decision making, it would almost be reasonable to classify his death as a suicide.

We also don't like this program because it forces us to buy a product just by simply living.

This argument really irritates me. You realize that all taxes are "forcing you to buy a product," right? You're forced to buy roads. You're forced to buy primary and high-school education. You're forced to buy military protection. All of these things are purchased with your tax money, which you are forced to pay. The only difference with ObamaCare is that, instead of the government taking your tax money and spending it to provide a service, they're saying you pay for the health insurance out of pocket. The difference is trivial.

To add to the conversation. There is such a thing as Classical Liberalism to which a lot of tea parties and some right wing republicans subscribe. One of the tenets is that scarcity of resources will inevitably lead to an underclass of people that will just not get enough resources to survive as well as the upper classes. Appealing to compassion is not going to work for those who subscribe to that, because they want, need and see as inevitable, an underclass that suffers.

My take on that, is that they only choose this belief, because they are convinced that they will be part of the upper class, because they believe themselves better than others. Most of them are wrong about that, but they will hopefully never find out, because american society has long outgrown is primitive view of the world.

I read a significant amount about the politics and economy of the US and this is simply another in a long list of articles and stories that makes me wonder simply one thing; "Why do so many Americans think that America is worth living in?". When I was young I really belived the US was the greatest country on Earth; nowadays I would rather be shot in the head than forced to visit the place. And the irony is that I can hear the cries of "Go ahead and die - we don't want you.", which is exactly the attitude that makes the US seem such an ugly country, populated largely by people with withered empathy. I'm sure there are decent people left, but they are rapidly becoming the timorous minority.

The average person is going to end up paying some taxes, sure, but you can certainly live in a charity homeless shelter or with your parents for free, make no income, and eat food from the Salvation Army, the local grocery store, or the food shelf and not pay anything in taxes. No one will be coming to your house and threatening you with fines or jail time for paying no taxes in these cases.

Do you really think that a guy who won't shell out $4 for PCN isn't going to find a way to avoid paying for individual health insurance?

I don't think the tooth infection case is a good example of why we need universal insurance (and just as importantly, access) since 99.999% of people could afford a week's worth of PenVK, insurance or not. Hell, I bet the Narc Rx was more expensive. However the case of the guy dying of pneumonia is more telling since I am a firm believer in doing away with the pre-existing condition problem our country has. Along with that of course would be the requirement to buy insurance. Once those two things are taken care of, some big strides will have been made. Yeah, there's a lot of other problems - mainly getting access to people with insurance or especially those on Medicaid. However, it would be a step in the right direction.

I'm not aware of the details of the dental story, but it sounds like you're assuming that the prescription written for the guy was for an inexpensive version of penicillin. This single example aside, I want to point out that often, even when aware that someone is indigent, doctors will prescribe medications without regard to the cost to their patient.

This happened frequently with my wife prior to the success of her disability claim and extension of medicare coverage. We paid for whatever healthcare we could afford out of pocket. We would sometimes be at the pharmacy filling prescriptions, only to realize that one of them was hopelessly out of reach financially. We would of course call the doctor and ask for a cheaper, often older medication, but the response wasn't always timely. I also have a friend who was recently indigent and had to go to the emergency room at a local hospital that has a program for indigent and low income people. The antibiotic he was prescribed was $160 dollars, which he, of course, couldn't afford. (and neither could I, or I would've gotten it for him.) Even after repeated attempts to get another prescription written, he wasn't able to get a new prescription until his next appointment a month later. This wasn't his poor decision, it was his doctor's. I, for one, am very happy that he didn't die during this time.

Details aside, I think it's short sighted and naive to believe that physicians always prescribe low cost medications to people. In my experience, physicians are simply unaware of the costs associated with different medications or they don't make the connection that someone who is uninsured can't afford that sexy new drug that the pharmaceutical rep just pitched to them.

I also think it's important to point out that low cost medications aren't always available.

"When we refuse to look at the humanity of a situation and would honestly say... let them die instead of me having to spend an extra dollar a week or so in taxes"

The choice in front of us is not: Pay $1 more, save a life vs Keep $1, let someone die. That is a very emotional way to frame the argument, but it is simply not accurate.

It is virtually impossible to capture the net effects of increased taxation, higher government spending on health care, and that process then 'saving' a life. Many assumptions are apparent in that scenario, and the opportunity costs are simply ignored.

"But, fuck them, because I've got mine"

Again, simplified to a emotional response, but not accurate. Disagreeing that the government should mandate care is not the same thing as saying "fuck them".

Also, the simple point is still true: It is not "Mr Smith's" responsibility to save "Mr Doe". This is not the same thing as saying "Fuck 'em".

It's actually fairly simple. And it's mindboggling to me that so many Americans seem to be unable to see it.

It comes down to 2 questions, really. First, are you willing to let people die from treatable conditions if they get sick and lack coverage ?

If the answer to that is "no", then there's only two logical conclusions:

Either we must be willing to pay for the treatment of those without coverage (say trough taxes), or else, we must be willing to create a system where people without coverage does not exist.

There's no other options.

And there's nothing special about healthcare. People who aren't in favor of the Iraq-war, are forced to pay for it trough taxes. Why is forcing people to pay for healthcare, so much worse than forcing people to pay for unwanted wars ?

The entire health care debate is stuck in a side issue and missing the point.

The core problem is that health care is too expensive. It is too expensive -with- insurance and it can be unobtainably expensive without it. This is an absolute and objectively verifiale fact. But instead of even attempting to lower the cost, we are bickering about how to split the check.

Is it fair to ask me or you to pay for someone elses care, even in part? No, it is not. Is it moral to let someone suffer and even die because we refuse to help foot the bill? No, it is not. But rather than go back and forth ad nauseum betweent the horns of this dillema, why don't we put that effort into making health care a reasonably priced industry?

For example, there are several medications that are useful both in human and veterinary care. In most cases, the pills intended for people and the pills intended for animals come off the same assembly line. But a pill going to a pharmacy costs ten times more AT A MINIMUM than the one going to a vet. Why is that? Because people will pay the premium, but animal owners will not waste the money.

You are right to be enraged at a callous disgregard for suffering in the name of money. But you are allowing your ire to be funneled towards people with a legitimate concern for their individual liberties, instead of at the institutions that truly embody it. The pharmaceutical industry being just the most obvious target.

Lovelace, you do an excellent job pointing out issues with our system that universal care will only compound. Doctors are not concerned about cost to the patient or insurance and having insurance makes the patient not care about cost. Universal care would have made your life more convenient because you wouldn't have to be a smart consumer but the result would be additional rises in cost for service. Over prescribing and prescribing unnecessarily expensive medicines are problems but universal care won't solve them.

dnivie, there are lot's of things I'm not willing to let people do (smoking, obesity) but if the only one they are hurting is themselves, I don't believe it is my right to control their behavior. So, it isn't quite so simple.

The question posed in the debate was about a person that could afford insurance, but didn't buy it. Not someone who couldn't afford it, and never had it. There is a huge difference - but let's not quibble on details.

Secondly, there never has been a true competitive market place. Opening up Insurance fees to cross state lines will change the market place. If there are better Insurance options available, more people will buy them.

Third, there are some among us who don't need it, because if something catastrophic should happen to them, they can afford to pay for their own treatment. I'm certainly not one of them, but I don't feel like they should be forced to buy something they don't need.

Finally, since my Insurance is provided through my provider - what choices do I have not take what they offer? The cost of which is going up, and up and up, as Employers have to offer the best solution they can afford, which more times than not means I share a greater portion of the burden.

"There is an important distinction you are missing. The federal government will only pay for so many residency positions, it does not say that a residency position cannot be created with private money. You think you are complaining about "government regulation", but in reality you are saying that the government should be subsidizing medical education to an even greater extent than it already is."

The only way to get residency is through federal program. Residency with private money is not authorized in any state.

I found Ron Paul's response perplexing (despite it's prevalence): if the patient can't pay, of course "our neighbors, our friends, our churches would do it" -- the community would come together and take care of the underserved. What Paul misses is that this is the central tenet of government healthcare -- Medicaid *is* our friends and neighbors coming together to take care of those who can't take care of themselves. He continued: "This whole idea -- that's the reason the cost is so high. The cost is so high because they dump it on the government, it becomes a bureaucracy."Private insurance has an overhead of 25-30%. Medicare's is 2%

Blatant lies like Medicare's overheaad is only 2% do not help your argument. It's only 2% because it doesn't count as overhead the entire cost of running the IRS as its collection agency and its use of other government agencies to do jobs that actual insurance companies pay for.In addition its totally artificial price controls are why costs are so high.

well said! to many of us are ignorant to others needs, reguardless if it's ones responsability over anothers. What happen to being brothers and sisters. caring for one another. Why is it every man for himself, is that why we are so devided?!

I never said that universal healthcare would solve that problem, but since you mention it, neither does the current system. The solution to that problem lies not in who pays for any particular individual's healthcare, which is the current debate, but in taking a serious look at the current pharmaceutical marketing system and a possibly requirement that physicians take courses in cost management. If physicians were to prescribe medications in a more educated way, as in only prescribing expensive new medications when absolutely necessary, we may even see an overall decrease in prices.

I think it's short sighted and naive to believe that physicians always prescribe low cost medications to people.

I'm talking about this particular patient. Patients who aren't allergic get penicillin for dental infections. That's just how it is. Clindamycin is the alternative, and the price has come down on that. The Wal-Mart in my area charges $52 for a typical clinda prescription.

I see 2-5 toothache patients per day, most of which are indigent (and drug seeking, but I digress), and this is how it is.

Our world is not perfect. Some people are going to die because they make poor decisions. In America, you have to allow people to make poor decisions.

As a Canadian, this news story and the statements made at the GOP debates make me feel very scared and sad.

I've had easily $40,000 in care from my country's health care system. I did not receive a single bill. I am not lazy. I was not sick by my own fault, unless one can be blamed for faulty genetics. I was not undeserving. No Canadian is EVER undeserving of care because no human being is ever undeserving of care.

Universal health care is not mandated charity. Universal health care is a nation supporting its citizens, recognizing that some of us will get sicker than others, and that when we all fund the system, we can all save more money while receiving equal care.

Universal health care means I never have to choose between going to an emergency room or paying a semester of university tuition.

So what about the cost to the economy of people that die early in their careers? It's not all roofers and people at mcdonalds... it's engineers, students, scientists, people with pre existing conditions (etc etc).

These people run the economy, and them dieing at a young age means that more has been invested in them than has been paid by them: they have unpaid debts: loans, mortgages.

So, i mean, I think we can agree in both a human and economic sense that saving lives has benefit.

"The only way to get residency is through federal program. Residency with private money is not authorized in any state."

This is 100% incorrect. You could have figured it out in 5 seconds with Google.

http://www.ama-assn.org/amednews/site/free/prl20130.htm

"Over the past six years, Rochester has added 50 resident positions above its Medicare payment cap, bringing its total residents to 550. Revenue from the university's clinical practices has primarily paid for the additional slots, Dr. Hartmann said."

to: anon re: my comment"Blatant lies like Medicare's overheaad is only 2% do not help your argument. It's only 2% because it doesn't count as overhead the entire cost of running the IRS as its collection agency and its use of other government agencies to do jobs that actual insurance companies pay for."

That's not a lie. That's efficiency.

Private insurance has higher overhead for 3 reasons:1) underwriting: deciding who to NOT cover in the first place2) fighting claims: deciding which bills to NOT pay for3) profit

It may seem "unfair" that the government system already has a revenue department and just sells plans to everyone over 65, but those are BENEFITS of a single-payer system.

To paraphrase, "Fuck him, the lazy mooching bastard got what he deserved. I got mine."

You really shouldn't paraphrase - you wind up changing the meaning of my comment. It is obviously a juvenile, oversimplification of what is a serious problem in our society - the sense of entitlement and loss of personal responsibility. Health care is NOT a right. Nor should it be a privilege. It should be affordable for all, but it also should be of high quality. The quality of health care in this country is unsurpassed by anything in this world. I would not travel anywhere else to receive my care. Government control can only decrease this quality - look no further than the CMS core measures and the recent example outlined here about rationing care in the state of Washington. Affordable care does NOT mean government run/ tax payer funded care. There are other options which do not entailing me to pay for this gentleman's health care. All he needed was $4 to pay for his penicillin until he was able to see a dentist. He was a victim of his own personal irresponsibility, not mine. To paraphrase my statement as "Fuck him, the lazy mooching bastard got what he deserved" is far from the truth. Because I have no sympathy for this particular person doesn't mean I'm heartless. There is a spectrum between "The government must run health care" and "you want people to die." Unfortunately, many liberals cannot see this.

As for the "I got mine," you have NO idea about my personal situation. I had posted this previously (in depth) but you obviously deleted my post, so I will summarize. I had saved money for years for the possibility of catastrophe. I have been unemployed for 6 months, refused to go on unemployment, and have lived on the money that I saved. During that time, I have had to pay for myself and my family's maintenance medications ($300/month), have had a medical procedure for which I did not have coverage and ultimately set up a payment plan with the hospital. I fortunately should be starting work again next month and will be getting coverage once again. But the bottom line is this - I made the best of a bad situation through personal responsibility and without any sense of entitlement. So, yeah, I got mine.

And lastly, the part that probably got this post deleted in the first place was my response to the following accusation, "They're lazy, irresponsible, poor, probably black, certainly unwashed and they have nice cell phones, so they are subhuman pieces of shit who deserve what's coming to them. " Please review my post and tell me where I mentioned race? You have injected racism into my argument and have assumed I am a racist. A typical liberal retort to any opposing viewpoint (just google Maxine Waters, Andre Carson, and Tea Party for recent evidence). Do you have any idea what race I am? I'm truly offended by this, as this goes way beyond believing someone is lazy and refuses to take responsibility for their lives. I do not stand for racism of any kind, and truly feel sorry for you. FYI, I have already contributed to Herman Cain's campaign.

Feel free to delete my post (again), but perhaps you should introspect a bit before you do.

The US may one day have universal health care, assuming that we do not run into mass inflation first. Then I assure you that only the wealthy will have access to quality health care, just as they did in the final days in the Soviet Union.

The rich will simply go to private doctors and foreign countries for treatments that will probably not even exist in the US.

The rest of us will be stuck with an increasingly bureaucratic and slow "free" health care system with doctors who lacked the skills to make it in the shrinking private sphere.

Yet, we, the poor and middle class, will fight tooth and nail for the free services, even as the system deteriorates, because of our inability to perceive what we have have lost. Namely, all of the advances that could have been achieved with the effort and money funneled away from entrepreneurs and into government. We will not understand why our doctors are not as skilled as the private doctors of the rich. We will believe the constant government propaganda assuring us that the system really works.

The same tired story is repeated over and over in every country when a government offers a "free" service at taxpayer expense, whether it be health care, education, or justice. The rich and well-connected continue to have access to a shrinking market in health care. The rest of us are stuck with the free alternative. The entrepreneurs who would otherwise be happy to become fabulously rich by providing low-cost alternatives to us, the poor and middle class, invest their time money in other, freer areas of the economy because they know that they cannot compete with the public alternative. Or they become corporatists and try to find ways to deliver the services themselves with government money (i.e., Halliburton, proprietary schools).

The system actually begins to become more fair when the bureaucracy, after sucking every taxpayer penny it can, finally collapses under the weight of its own incompetence and greed. The diminishing level of service offered by the government finally opens up opportunities for entrepreneurs to innovate and make money, although not before enormous suffering is endured by those who had become dependent on the free service.

I am not an economist, a philosopher, or a writer. I know almost nothing about the history of Standard Oil, and I have no idea how to discuss theoretical questions like the one asked of Ron Paul, although I certain am sure there are some very good responses. All I know is what I see with my own eyes, read in the news, and perceive with my own common sense. And all of these sources of information have convinced me that the above cycle is true and happens any time government decides to offer me a free service (at my own expense), whether it be health care, education, or justice, just as surely as I know that invading Iraq was a bad idea.

When someone asks how I can oppose government health care when so many people are uninsured, I would tell them that it is not due callous indifference like what the Republicans at the debate, who likely have no understanding of entrepreneuralism or markets at all based on my experience. It is not even due to an abstract notion like private property or the non-aggression principle. I simply believe that the only way we will every approach a truly "universal" health care system is to allow one to develop that is based totally on the free market or, as I think this is a loaded term, one that develops in an environment where there are as few disincentives as possible for extremely smart and motivated people to make a lot of money by providing me with health care that I, a poor man, can afford. Those circumstances seem to provide the greatest benefit for me; they certain seem to provide more benefit than government. As such, I am resemble a liberal in that I wish to achieve the end of prosperity for all; I just think that liberal path of government demonstrably leads to oligarchy. I wish Ron Paul had said something to a similar effect.

I have a medically complex child who was covered by a SELF-PAY plan when all of her medical issues were discovered. The plan shut down (because it wasn't making enough money), we looked for new coverage for her, and we were told by the agent that we needed to withdraw our app unless we wanted a permanent denial on her record. After traveling down all avenues (including the hig risk pool), our only option was for my husband to take a pay cut to qualify for state CHIP coverage.

Last night, we picked up two meds for her because she has pneumonia...it would have cost $303.99 and $603.99 for those TWO meds without insurance. We can't NOT have insurance with her, but our only option is taking a pay cut (great for the economy, right?!).

I did some advocacy work trying to get our state to create a buy-in system for CHIP in our state, but it didn't happen. If it wasn't for the CDF, we may never have figured out how to get coverage for her and I'm sure there are people in the same boat we were that haven't found the answer...those months without coverage for her were constantly terrifying. There ARE good, hard-working people who don't have insurance through NO FAULT of their own....it is not always a CHOICE or a situation that comes from laziness. It burns me up to think there are people who would let my baby die (but who are SO concerned about the "rationing" of their own healthcare) and feel that thought is worth a good laugh. Thanks for this post.

Do you not piece together the other issues as well though. I mean, I'm a Canadian and even though our health care is coming down to meet the American system, I have been on the receiving end of one of the best health care systems in the world for a long while, and I know that health care in the US has a long way to go even with the few gains that have been made and seem likely to get eaten away or worked around in short order anyway but this is no good reason to be trying to get votes for someone who's turned out to be a bigger liar and a worse war criminal than even "W". C'mon folks, there's a bigger picture and these are very dangerous times. The chickens are coming home to roost, the government IS NOT in charge and we cannot vote our way out of this mess. The banks have to fall. The masters of the universe have to be dethroned. It's revolution time folks.

Have just stumbled upon this blog and as an ER and PICU nurse, I really enjoy it. I don't know what the solution is to the healthcare problem, but it seems like at the crux of it, there are two problems I just don't see a solution to:

1. Health care costs money. No matter what system we have in place to pay for it, it is NOT free and never will be, just like cars and houses will never be free. Maybe we can afford to give basic care (PCP visits, vaccinations, etc) to the entire population but can we really ever afford to offer every available therapy to every single person who needs it?

2. No matter what system is in place, you can't get around personal choice. Some people, even when offered "free" care, will choose not to utilize it and/or to utilize it inappropriately. Until we figure out a way to alter people's personal choices...especially as it relates to the overweight and obese population...health care will continue to be astronomically expensive.

Shadowfax

About me: I am an ER physician and administrator living in the Pacific Northwest. I live with my wife and four kids. Various other interests include Shorin-ryu karate, general aviation, Irish music, Apple computers, and progressive politics. My kids do their best to ensure that I have little time to pursue these hobbies.

Disclaimer

This blog is for general discussion, education, entertainment and amusement. Nothing written here constitutes medical advice nor are any hypothetical cases discussed intended to be construed as medical advice. Please do not contact me with specific medical questions or concerns. All clinical cases on this blog are presented for educational or general interest purposes and every attempt has been made to ensure that patient confidentiality and HIPAA are respected. All cases are fictionalized, either in part or in whole, depending on how much I needed to embellish to make it a good story to protect patient privacy.

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